Dr. Hanscom's Blog Avoid Surgery by Raising the Pain Threshold

My Friend’s Back
A friend of mine asked me for an opinion a couple of years ago about his back. I was giving him advice as a friend, not as a surgeon. He was having some pain and numbness down the side of his leg. It was down the distribution of his 5th lumbar nerve root.
His MRI scan showed that there was a bone spur between the 5th lumbar and 1st sacral vertebra as it exited out of the side of the spine. It was surrounding the 5th lumbar nerve root. It was my feeling that surgery might help but I also thought he might avoid surgery with certain exercises that flexed his spine and also working on some the Mind Body Syndrome principles.The Surgery Didn’t Help

He elected to go ahead with surgery. He improved for a couple of months and the pain returned except that it was worse. He then underwent a second operation about six months later that did not help and in fact worsened his pain. He asked me again what I thought he should do next.He Took Charge

About six weeks before I talked to him he had fired everyone and stopped everything. No more doctors, medications, or surgery. Within a week of making that decision his pain disappeared. He had taken complete charge of his care.The Bone Spur is Still There

What makes his story more interesting was that when I looked at the MRI scan done after his second operation the bone spur was still there. The surgeon had missed it. He had worked on the middle part of his spine freeing up the 1st sacral nerve root, not the L5 nerve root. He had needed to remove the bone spur out to the side of the spinal canal, not the middle.Another Patient

I had another woman a couple of years ago who had pain down both of her legs in the pattern of the L5 nerve root. She had resisted the DOCC project for a long time. She decided to undergo surgery to free up both of the L5 nerve roots. She did have significant spurring touching both of the nerves. When she made the decision to have the operation she also engaged in the DOCC project. When she came in for her pre-operative visit her leg symptoms disappeared. I cancelled her surgery.They Both Had Structural Problems
In both of these cases there were structural problem with matching symptoms. In the first case, if the L5 nerve root had been correctly freed up his pain would have disappeared after the first operation or the second operation. As the bone spur was never removed it now was clear that he could have gotten the same improvement without any surgery. With the second case she would have also done well with surgery. Both of them solved their own problem with engagement and taking charge. That is why my book is title, “Back in Control.” Every patient I have seen get better has taken full responsibility for their pain and care.Raising the Pain Threshold
When your nervous system calms down utilizing Mind Body Syndrome principles the threshold for sensing pain is raised. I am sure that the structural lesions in their spines are still firing pain impulses to the brain. It is just that they are now below the elevated pain threshold and are not interpreted as pain.
What did they do? They both took charge of their problem. They took control, which instantly decreases anxiety. That, in and of itself, is a major step in calming down the nervous system. Their pain did not just decrease it disappeared.Surgery is Still an Option

In the future there is a high chance that the symptoms will re-appear under a certain level of outside stress. I am now used to having my patients go through the steps that originally calmed them down and the symptoms will reliably disappear. Remember that pain pathways are permanent. I also reassured them that if the symptoms don’t diminish I could always perform an operation with good success.Why Not Just Do the Surgery?
You might be asking, “Why not do the operation and then they would not have to worry about it in the future?” There are a several reasons. First, even with a successful operation it is common for pain pathways to get fired up under stress even if there is not a recurrence of the structural problem. Second, even the simplest operation has risks. I could write a book of simple operations going bad. Third, with spine surgery you always cause the formation of scar tissue that can be permanently irritating. You are just better off avoiding surgery if at all possible.The Change in My Thinking
I now have over a dozen cases similar to these two. It has caused me to change my thinking about the timing and role of surgery. I use to think that surgery was always required in the presence of a structural problem. My conversation with my patients would be, “Let’s get the surgery done and we’ll work through the rehab later. You cannot rehab a structural problem.”
My discussion now is, “I am happy to perform your surgery but I have seen patients go to pain free even in the presence of a structural problem. If we can calm down your nervous system your post-operative pain will be less and easier to control. Maybe we don’t even need to undergo surgery.”The DOCC project is a Process in Evolution
I am a surgeon. My thinking around the DOCC project evolves every month. The idea that a person could raise their pain threshold enough to avoid surgery simply by taking complete charge of their decision-making has been surprising to me.

There are a several reasons. First, even with a successful operation it is common for pain pathways to get fired up under stress even if there is not a recurrence of the structural problem. Second, even the simplest operation has risks. I could write a book of simple operations going bad. Third, with spine surgery you always cause the formation of scar tissue that can be permanently irritating. You are just better off avoiding surgery if at all possible.

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That sure summarizes it in a nutshell. I had a herniated disk between L3/L4 and hurt like heck. It went away when I got a big check and my social life improved. Then the pain came back after I took a big fall out running. However, I was also really emotionally and physically stressed out at the same time. Now, the pain is going away as I calm down and my life improves. Obviously, the nerve root between L3/L4 was impinged the whole time, but I didn't feel any pain until external and internal stressors made me more sensitive to it so that I was paying attention to the pain messages to the point of obsession.

During my recent journey to recovery from chronic back pain, I read your terrific book. Your book was what convinced me once and for all that most of my pain was TMS. Because of my osteoporosis, surgery would not be a really good option for me. I realized that scoliosis and osteoporosis are not normally painful conditions unless a fracture occurs. I have gone back to being my usually active self and feeling much better with very little pain, most of which I am able to ignore completely. My husband is a doctor and he always thought that I suffered from TMS. Your book helped me greatly to get my life back. Thank-you.

What I liked most about the book, and this is why I chose to read it, is that it is written by a successful orthopedic surgeon, who makes an airtight argument that Dr. Sarno was right about the majority of cases of back pain: The pain is not caused by or necessarily related to some structural disorder. Also that surgery for these sort of problem rarely, if ever, solves the pain problem. Prior to reading this book, I believed maybe 75% that my LBP and sciatica were TMS, but that is not good enough to effect a cure. I needed to believe that 100%. My own husband had told me many times that my structural abnormalities were not normally painful conditions and it was probably my mind that was responsible for my pain. Once I read this book, I became unstuck and closed the belief gap to 100%. That got me on my way to healing. I am so grateful to Dr. Hanscom for writing this book.

What I liked most about the book, and this is why I chose to read it, is that it is written by a successful orthopedic surgeon, who makes an airtight argument that Dr. Sarno was right about the majority of cases of back pain: The pain is not caused by or necessarily related to some structural disorder. Also that surgery for these sort of problem rarely, if ever, solves the pain problem. Prior to reading this book, I believed maybe 75% that my LBP and sciatica were TMS, but that is not good enough to effect a cure. I needed to believe that 100%. My own husband had told me many times that my structural abnormalities were not normally painful conditions and it was probably my mind that was responsible for my pain. Once I read this book, I became unstuck and closed the belief gap to 100%. That got me on my way to healing. I am so grateful to Dr. Hanscom for writing this book.

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Chickenbone,

Would you recommend it for someone who suffers from chronic pain that is not back pain?

Also, does he have recommendations other than "accepting" or "ignoring" the pain? I am feeling very frustrated lately by people who say you must do this in order to get past your pain, because I just don't know how to do it!

Hi gailnyc, I had defined 3 steps that I needed to accomplish in order to get over my pain. My back pain was the worst, but I also have allergies, headaches and sleep problems that I think are also related to TMS. I tackled the back pain first. Remember that symptoms will come and go and move around during the healing process. After my back pain went away, I had a few bouts with these other issues as well as short pain relapses.

My first step was to believe 100% that my pain was TMS. This is specifically what this book did for me. The second step was to internalize the idea that the pain was harmless and that pain did not mean damage. The third was to not care if I had pain or not. This last step causes the pain to recede into the background of your life. It is not quite the same as ignoring the pain, but involves living your life in a more relaxed manner and making peace with the pain. This often means that you promise to do the mental work necessary to keep the pain away. This means that you must stop making "ridding yourself of pain" your goal and you must not think that your life will be wonderful without the pain. Believe me it won't be. Both these attitudes will feed the pain strategy. Most of the time, pain does not just disappear all of a sudden, but there are some exceptions. Obviously neither you or I are one of those exceptions. All three of these steps are very difficult to accomplish. At least that is how I did it. On another TMS forum, there is a thread that is constantly updated called "The Keys to Healing" by Ace1. These worked very well for me on a day-to-day basis.

I think this book can apply to pain other than back pain, but I believe any pain should be checked out first. One of the things you learn about yourself during the healing process is what is and is not TMS pain. Also, I don't believe that there is a clear boundary between physical and TMS pain. For example, pain often starts out acute and then, if the person is prone to TMS, became chronic TMS pain later. Some pain is all TMS. I have found that healing mentally will lessen the intensity of all pain.

The Psychology utilized in the book is strictly CBT (Cognitive Behavioral). I consider this somewhat light weight and does not work for everyone. But remember, he is a MD, not a Psychologist.

Chickenbone, thank you so much for the helpful explanation. Making peace with the pain is what I need to work on. I've been re-reading The Divided Mind, but I get tired of Sarno's anti-medical-establishment rhetoric (not that I don't think he's right--it's just that reading it over and over again grows tiresome). So maybe I will try Dr. Hanscom's book next.

My Friend’s Back
A friend of mine asked me for an opinion a couple of years ago about his back. I was giving him advice as a friend, not as a surgeon. He was having some pain and numbness down the side of his leg. It was down the distribution of his 5th lumbar nerve root.
His MRI scan showed that there was a bone spur between the 5th lumbar and 1st sacral vertebra as it exited out of the side of the spine. It was surrounding the 5th lumbar nerve root. It was my feeling that surgery might help but I also thought he might avoid surgery with certain exercises that flexed his spine and also working on some the Mind Body Syndrome principles.The Surgery Didn’t Help

He elected to go ahead with surgery. He improved for a couple of months and the pain returned except that it was worse. He then underwent a second operation about six months later that did not help and in fact worsened his pain. He asked me again what I thought he should do next.He Took Charge

About six weeks before I talked to him he had fired everyone and stopped everything. No more doctors, medications, or surgery. Within a week of making that decision his pain disappeared. He had taken complete charge of his care.The Bone Spur is Still There

What makes his story more interesting was that when I looked at the MRI scan done after his second operation the bone spur was still there. The surgeon had missed it. He had worked on the middle part of his spine freeing up the 1st sacral nerve root, not the L5 nerve root. He had needed to remove the bone spur out to the side of the spinal canal, not the middle.Another Patient

I had another woman a couple of years ago who had pain down both of her legs in the pattern of the L5 nerve root. She had resisted the DOCC project for a long time. She decided to undergo surgery to free up both of the L5 nerve roots. She did have significant spurring touching both of the nerves. When she made the decision to have the operation she also engaged in the DOCC project. When she came in for her pre-operative visit her leg symptoms disappeared. I cancelled her surgery.They Both Had Structural Problems
In both of these cases there were structural problem with matching symptoms. In the first case, if the L5 nerve root had been correctly freed up his pain would have disappeared after the first operation or the second operation. As the bone spur was never removed it now was clear that he could have gotten the same improvement without any surgery. With the second case she would have also done well with surgery. Both of them solved their own problem with engagement and taking charge. That is why my book is title, “Back in Control.” Every patient I have seen get better has taken full responsibility for their pain and care.Raising the Pain Threshold
When your nervous system calms down utilizing Mind Body Syndrome principles the threshold for sensing pain is raised. I am sure that the structural lesions in their spines are still firing pain impulses to the brain. It is just that they are now below the elevated pain threshold and are not interpreted as pain.
What did they do? They both took charge of their problem. They took control, which instantly decreases anxiety. That, in and of itself, is a major step in calming down the nervous system. Their pain did not just decrease it disappeared.Surgery is Still an Option

In the future there is a high chance that the symptoms will re-appear under a certain level of outside stress. I am now used to having my patients go through the steps that originally calmed them down and the symptoms will reliably disappear. Remember that pain pathways are permanent. I also reassured them that if the symptoms don’t diminish I could always perform an operation with good success.Why Not Just Do the Surgery?
You might be asking, “Why not do the operation and then they would not have to worry about it in the future?” There are a several reasons. First, even with a successful operation it is common for pain pathways to get fired up under stress even if there is not a recurrence of the structural problem. Second, even the simplest operation has risks. I could write a book of simple operations going bad. Third, with spine surgery you always cause the formation of scar tissue that can be permanently irritating. You are just better off avoiding surgery if at all possible.The Change in My Thinking
I now have over a dozen cases similar to these two. It has caused me to change my thinking about the timing and role of surgery. I use to think that surgery was always required in the presence of a structural problem. My conversation with my patients would be, “Let’s get the surgery done and we’ll work through the rehab later. You cannot rehab a structural problem.”
My discussion now is, “I am happy to perform your surgery but I have seen patients go to pain free even in the presence of a structural problem. If we can calm down your nervous system your post-operative pain will be less and easier to control. Maybe we don’t even need to undergo surgery.”The DOCC project is a Process in Evolution
I am a surgeon. My thinking around the DOCC project evolves every month. The idea that a person could raise their pain threshold enough to avoid surgery simply by taking complete charge of their decision-making has been surprising to me.

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I was thinking of have surgery but opted out and I had a steroid injection into my L4-5 S1...did it work? no. I believe the scarring actually made it worse. The effects that stress can have on the body is astounding.

This is very interesting post. To clarify, there could be two interpretations of these stories: that the structural problem was not really the true source of pain? In other words, it was TMS all along? Or, is Dr. Hanscomb making the point that even though there is a structural cause for the pain, it is possible, through reprogramming and CNS calming methods, that the pain can be eliminated by raising the pain threshold? Since he doesn't mention TMS, I'm assuming the latter.

In either case, Mtngal, Dr. Hanscomb seems to believe that the real source of the pain is physical pressure on the adjacent nerve from a spinal abnormality. I think Dr Sarno points out that this is a physical impossibility since nerves are soft tissue surrounded by soft tissue. There's plenty of room for "give". Dr Hascomb also seems to be endorsing current medical views that emotions can reduce the perception of pain, but not actually cause or originate the pain. It sounds as though his views are actually quite conventional.

I am sure that the structural lesions in their spines are still firing pain impulses to the brain. It is just that they are now below the elevated pain threshold and are not interpreted as pain.

Thanks BruceMC for you view on this, which is the same as mine. As chickenbone points out, it seems like it's more in line with CBT, which I believe Dr. Sarno says doesn't really work too well. I did read Dr. Hanscomb's book and I think what' s important to take away from it is that degenerative disc disease does NOT cause low back pain - he quit doing surgery for that about 8 years ago. Also he advocates "free writing" where you record all your negative thoughts so you can become detached from them and hopefully reprogram your pain pathways.. anybody else read his book?

One fly in the ointment of Dr Hanscomb's theory is that a patient can be experiencing completely crippling lower back pain and sciatica and not have any spinal abnormalities whatsoever, at least none that can be detected by an MRI or CT scan. If bodymind techniques work in those cases to eliminate the patient's pain, it would seem that some other process is at work, like Dr Sarno's TMS.